Nursing Elites

1. During an acute exacerbation of asthma, what is the nurse's first action for a client experiencing this condition?

• A. Administer a bronchodilator as prescribed.
• B. Check the client's oxygen saturation.
• C. Reassure the client and encourage deep breathing.
• D. Provide emotional support to reduce anxiety.

Correct answer: A

Rationale: The correct first action when managing an acute exacerbation of asthma is to administer a bronchodilator as prescribed. Bronchodilators help open the airways and improve breathing in individuals experiencing an asthma exacerbation. Checking oxygen saturation (Choice B) is important but not the first action. Reassuring the client and encouraging deep breathing (Choice C) can be beneficial but should come after administering the bronchodilator. Providing emotional support to reduce anxiety (Choice D) is important but is not the initial priority in managing an acute exacerbation of asthma.

2. Following discharge teaching, a male client with a duodenal ulcer tells the nurse that he will drink plenty of dairy products, such as milk, to help coat and protect his ulcer. What is the best follow-up action by the nurse?

• A. Encourage the client to drink milk
• B. Review with the client the need to avoid foods that are rich in milk and cream
• C. Instruct the client to take antacids instead
• D. Advise the client to monitor their symptoms

Correct answer: B

Rationale: The client should be advised to avoid foods rich in milk and cream. Although they provide temporary relief, dairy products, especially milk, stimulate gastric acid secretion, which can exacerbate the symptoms of a duodenal ulcer. Encouraging the client to drink milk (Choice A) would be counterproductive and could worsen the condition. Instructing the client to take antacids (Choice C) may provide symptomatic relief but does not address the root cause of the issue. Advising the client to monitor their symptoms (Choice D) is vague and does not provide specific guidance on managing the duodenal ulcer. Therefore, the best action is to review with the client the need to avoid foods rich in milk and cream to ensure proper ulcer management.

3. The nurse is caring for a client with acute pancreatitis who is reporting severe abdominal pain. Which nursing intervention should the nurse implement first?

• A. Assess the client's bowel sounds
• B. Administer prescribed pain medication
• C. Encourage the client to sit upright
• D. Provide clear fluids to the client

Correct answer: B

Rationale: In a client with acute pancreatitis experiencing severe abdominal pain, the priority nursing intervention is to provide pain relief. Administering prescribed pain medication is essential to improve comfort and reduce pain, which can help stabilize the client's condition. Assessing bowel sounds (Choice A) may be necessary but is not the immediate priority over pain management. Encouraging the client to sit upright (Choice C) and providing clear fluids (Choice D) are not the primary interventions for addressing severe abdominal pain in acute pancreatitis.

4. A client with hyperthyroidism is admitted for total thyroidectomy. What is the nurse's priority post-operative intervention?

• A. Monitor the client's calcium levels for hypocalcemia.
• B. Monitor for signs of respiratory distress.
• C. Administer oral calcium supplements.
• D. Elevate the head of the bed to 45 degrees.

Correct answer: A

Rationale: The correct answer is to monitor the client's calcium levels for hypocalcemia. After a total thyroidectomy, there is a risk of accidental removal or damage to the parathyroid glands, leading to hypocalcemia. This complication can manifest within the first 24-48 hours post-op. Monitoring calcium levels is crucial to prevent serious complications such as tetany or seizures. While monitoring for respiratory distress is important, it is not the priority in this case. Administering oral calcium supplements should only be done based on the healthcare provider's prescription and after assessing the client's calcium levels. Elevating the head of the bed to 45 degrees is beneficial for respiratory function but is not the priority intervention for a client at risk for hypocalcemia post-thyroidectomy.

5. A client recently started on warfarin therapy. What laboratory value is most important to monitor for this client?

• A. Platelet count
• B. Prothrombin time (PT)
• C. Creatinine level
• D. Blood urea nitrogen (BUN)

Correct answer: B

Rationale: Prothrombin time (PT) is the most important laboratory value to monitor for clients on warfarin therapy. PT helps determine how long it takes blood to clot and ensures the warfarin dose is within the therapeutic range to prevent either excessive bleeding or clotting. Monitoring platelet count is important for assessing the risk of bleeding, but PT is more specific to warfarin therapy. Creatinine level and BUN are indicators of kidney function and are not directly related to warfarin therapy.

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